Fillable Get File-uuid-9b2fd3b3-4a49-4917-ae9b-51cc93d2c822-groupId-4329369 - GC-7-18

Fill Online, Printable, Fillable, Blank Get File-uuid-9b2fd3b3-4a49-4917-ae9b-51cc93d2c822-groupId-4329369 - GC-7-18 Form

Use Fill to complete blank online CALIFORNIA MARITIME ACADEMY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Get File-uuid-9b2fd3b3-4a49-4917-ae9b-51cc93d2c822-groupId-4329369 - GC-7-18

On average this form takes 8 minutes to complete

The Get File-uuid-9b2fd3b3-4a49-4917-ae9b-51cc93d2c822-groupId-4329369 - GC-7-18 form is 2 pages long and contains:

  • 0 signatures
  • 21 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California Maritime Academy

BROWSE CALIFORNIA MARITIME ACADEMY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
5BMedical Benefits – Claim Instructions
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: For your
protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to
an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the
department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas and Missouri Residents: Any person who knowingly and
with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or
conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with
intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and
Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may
include imprisonment, fines, or denial of insurance benefits. Attention Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention
New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or
misleading information is subject to criminal and civil penalties. Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person
who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance
or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law.
Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an
application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits
a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a
fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the
jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or
other person files an application for insurance or statement of claim containing any intentional misrepresentation of material
fact or conceals, for the purpose of misleading, information
concerning any fact material
thereto may
commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont
Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing
any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and
may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or
other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
NOTE: INCOMPLETE CLAIM FORMS WILL BE RETURNED TO YOU FOR MISSING INFORMATION. THIS WILL DELAY THE PROCESSING OF THE CLAIM. FOR
FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION
REGARDING ELECTRONIC CLAIM SUBMISSIONS.
3BTO THE MEMBER
1. Complete items one (1) through twenty-one (21) in full.
2. Complete items twenty-two (22) through twenty-six (26) only if other medical coverage exists.
3. Be certain to sign the authorization to release information in block twenty-seven (27).
4. If you wish to have your benefits for this claim paid directly to your physician or supplier, sign block twenty-eight (28).
5. If you have submitted a request for benefits to another plan, including Medicare, attach a copy of the bills you submitted to the other plan and the explanation of
benefits you received from the other plan.
6. Attach itemized bills or ask your health care provider to complete the applicable section on the reverse side. The bills must include:
- patient's name - condition being treated - type of service(s) rendered
- date(s) of service(s) - relationship to member
If this information is missing, write it on the bill and sign your name.
7. If prescription drugs are covered under your plan, submit receipts or a Prescription Drug Record form. Receipt must contain:
- drug name - purchase date - prescription number - pharmacy name/address
- dose per/day - nature of illness or injury - quantity
- charge - strength - physician's name
This information can be copied from the prescription bottle or box.
8. Retain copies of your bills for your record.
9. Refer to the back of your ID card for claim mailing address.
TO THE PHYSICIAN OR SUPPLIER
1. Complete items twenty-nine (29) through forty-five (45) in full.
2. If the member indicates that benefits should be paid directly to the physician or supplier, then these benefits will be sent directly to you with an information copy of the
transactions to the member.
GC-7-42 (4-12) Page 1 of 2
4BMedical Benefits Request
Refer to the back of your ID card
for claim mailing address
0BTO BE COMPLETED BY MEMBER
1. School Name
2. Policy/Group Number
3. Member’s Aetna ID Number
4. Member’s Name
5. Member’s Birthdate (MM/DD/YYYY)
6. Member’s Address (include ZIP Code) Address is new
7. Member’s Daytime Telephone
Number
( )
8. Patient's Name
9. Patient's Aetna ID Number
10. Patient's Birthdate (MM/DD/YYYY)
11. Patient's Relationship to Member
Self Spouse Child Other
12. Patient's Address (if different from member)
13. Patient's Gender
Male Female
14. Full Time Student
No Yes
15. Patient's Expected Graduation Date
16. Name of School and City
17. Patient's Marital Status
Married Single
18. Is patient employed?
No Yes
19. Name & Address of Employer
20. Is claim related to an accident?
No Yes If Yes, date U U time U U am pm
21. Is claim related to employment?
No Yes
22. Are any family members expenses covered by another group health plan, group pre-
payment plan (Blue Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any
federal, state or local government plan?
No Yes
23. If Yes, list policy or contract holder, policy or contract number(s) and name/address of
insurance company or administrator:
24. Member’s ID Number
25. Member’s Name
26. Member’s Birthdate (MM/DD/YYYY)
27. To all providers of health care:
You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies (“Aetna”), and any independent claim administrators and consulting health professionals
and utilization review organizations with whom Aetna has contracted, information concerning health care advice, treatment or supplies provided the patient (including that relating to
mental illness and/or AIDS/ARC/HIV). This information will be used to evaluate claims for benefits. Aetna may provide the employer named above with any benefit calculation used in
payment of this claim for the purpose of reviewing the experience and operation of the policy or contract. This authorization is valid for the term of the policy or contract under which a
claim has been submitted. I know that I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.
Patient's or Authorized Person's Signature
Date U
28. I authorize payment of medical benefits to the physician or supplier of service.
Patient's or Authorized Person's Signature
Date U
1BTO BE COMPLETED BY PHYSICIAN OR SUPPLIER
29. Date of Illness (first symptom) or injury
(accident) or pregnancy (LMP)
30. Date first consulted you for this condition 31. If patient has had similar illness or injury, give
dates
32. If an emergency check here
emergency
33. Name of referring physician (e.g., Public Health Agency)
34. For services related to hospitalization give hospitalization dates
admitted discharged
35. Name & address of facility where services rendered (if other than home or office)
36. Diagnosis or nature of illness or injury (please indicate primary and secondary)
1.
2.
3.
4.
2B37. Procedures, Medical Services, Supplies Furnished
Date of
Service
Place of
Service*
Procedure Code
Identify** Description of Service
Type of
Service
Charges
Days or
Units
Diagnosis
Code 
Administrative
Use Only
39. Telephone Number
( )
40. Enter the taxpayer identifying number to be used for
1099 reporting purposes. You are required under
authority of law to furnish your taxpayer identifying
number.
38. Physician's Name & Address (include ZIP Code)
41. Patient Account Number
42. Total charge $
Amount paid $
Balance due $
43. Physician's or Supplier's Signature
44. National Provider Identifier 45. Date
* Place of Service Codes:
1 - (IH) - Inpatient Hospital
2 - (OH) - Outpatient Hospital
3 - (O) - Office Visit
4 - (H) - Patient Home
5 - - Day Care Facility (PSY)
6 - - Night Care Facility (PSY)
7 - (NH) - Nursing Home
8 - (SNF) - Skilled Nursing Facility
9 - - Ambulance
0 - (OL) - Other Location
A - (IL) - Independent Laboratory
B - - Other Medical Surgical Facility
C - (RTC) - Residential Treatment Center
D - (STF) - Specialized Treatment Facility
Type of Service Codes:
1 - Medical Care
2 - Surgery
3 - Consultation
4 - Diagnostic X-Ray
5 - Diagnostic Laboratory
6 - Radiation Therapy
7 - Anesthesia
8 - Assistance at Surgery
9 - Other Medical Service
0 - Blood or Packed Red Cells
A - Used DME
M - Alternate Payment for Maintenance Dialysis
Y - Second Opinion on Elective Surgery
Z - Third Opinion on Elective Surgery
** Please Use Current Procedural Terminology Codes For Surgery Please Use ICD•9•CM For Discharge Diagnosis
GC-7-42 (4-12) Page 2 of 2
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Get File-uuid-9b2fd3b3-4a49-4917-ae9b-51cc93d2c822-groupId-4329369 - GC-7-18

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 June 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document